Employment Application

The Graham Academy is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.

Additional Information

List by number and expiration date any professional licenses or certificates issued by The Commonwealth of Pennsylvania or Professional Association.

Do you have a valid driver's license?YesNo

Driver's License State

Driver's License Number

Driver's License Expiration Date

List Any Accidents or Moving Violations in the past three (3) years.

Do you have any physical/medical/emotional impairment, which would interfere with your ability to perform the job for which you have applied with or without reasonable accommodation?

Were you ever injured while on the job?YesNo

If yes, provide details.

Have you ever used controlled substances (i.e. illicit drugs)?YesNo

If yes, provide details.

Have you ever abused alcoholic beverages?YesNo

If yes, provide details.

Have you ever worked for The Graham Academy before?YesNo

If yes, list dates.

Have you ever worked for another company in the social service field?YesNo

If yes, provide details.

List name and addresses of all social services agencies.

Did any employment in social services end in involuntary termination due to abuse or neglect?YesNo

If yes, please explain.

Other reasons for termination from any other company/organization.

Were you ever convicted of a criminal offense of any kind, summary, misdemeanor or felony, or have you ever-forfeited bond or collateral in connection with criminal charge? Is any criminal charge against you now pending? (Omit (1) minor traffic violation, and (2) any offense committed before your eighteenth birthday, which was finally adjudicated in a juvenile court or under a youth offender law.) Conviction of a criminal offense is not necessarily a bar to employment. Each case is considered on its own merits.YesNo

If yes, provide details.

Employment History

List your complete employment record. Begin with your present position and work backwards. Include all full and part time employment and military service. Please explain any gaps in your employment history.

Employer 1

Company Name

Company Address

Company Phone

Supervisor Name

May we contact this employer?YesNo

Start Date (MM/YYYY)

End Date (MM/YYYY)

Reason for Leaving

Average Hours Worked per Week

Final Salary

Job Title

Number of Employees Supervised

Specify Duties

Employer 2

Company Name

Company Address

Company Phone

Supervisor Name

May we contact this employer?YesNo

Start Date (MM/YYYY)

End Date (MM/YYYY)

Reason for Leaving

Average Hours Worked per Week

Final Salary

Job Title

Number of Employees Supervised

Specify Duties

Employer 3

Company Name

Company Address

Company Phone

Supervisor Name

May we contact this employer?YesNo

Start Date (MM/YYYY)

End Date (MM/YYYY)

Reason for Leaving

Average Hours Worked per Week

Final Salary

Job Title

Number of Employees Supervised

Specify Duties

Business and Professional References

Please list four business/professional references. Please exclude your most recent employer and any person(s) related to you. These references must be addressed accurately.

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Applicant Acknowledgement and Authorization

Please read carefully be accepting.

I consent to the release of information concerning my capacity and/or all aspects of prior job performance by employers, educational institutions, law enforcement agencies, including but not limited to, ChildLine, and other individuals and agencies to duly accredited investigators, human resources staff for the purpose of determining my eligibility and suitability for employment.

I certify that all statements made on this application and any attached papers are true and complete to the best of my knowledge. I understand that information on this application may be subject to investigation and verification and that any misrepresentation or material omission may cause my application to be rejected, my name to be removed from the eligible register and/or subject me to dismissal from employment.

Additionally, in consideration for employment with The Graham Academy, if employed, I agree to conform to the rules, regulations, policies and procedures of The Graham Academy at all times and understand that such obedience is a condition of employment. I understand that due to the nature of The Graham Academy’s business, attendance and punctuality are considered essential requirements of every job at The Graham Academy and that poor attendance or tardiness will result in disciplinary action.

I also understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. The Graham Academy utilizes “employment at will” with either the employee or employer able to terminate the employment at any time according to procedures set forth in the policy manual.

I acknowledge that I have read, understood and agree to the above statements.